Failure to Update Facility Assessment Tool with Accurate Census
Penalty
Summary
The facility failed to revise and provide an updated average daily census in its Facility Assessment Tool, which is used to evaluate the resident population and identify necessary resources for care and services. On review, the census for a specific date showed 54 residents, while the Facility Assessment Tool, last updated several months prior, listed an average daily census of 51 residents. During an interview and record review, the Administrator acknowledged that the assessment did not reflect the current census, with three residents unaccounted for, and confirmed responsibility for updating the tool. The Administrator also stated that the Facility Assessment Tool should be updated annually and as needed when there are changes in the resident population or facility operations. The facility's policy indicated that the Facility Assessment must be reviewed and updated annually or sooner if there are significant changes in census or resident acuity. CMS guidance further requires that the assessment include an evaluation of resident diseases, conditions, and acuity, and be updated whenever there is a substantial change. The failure to maintain an accurate and current Facility Assessment Tool had the potential to place residents at risk for delays in care and treatment services.